History and exam

Key diagnostic factors

common

presence of risk factors

Key risk factors include cleft palate, adenoid hypertrophy, allergic rhinitis, chronic rhinosinusitis, and neoplasm of the nasopharynx or infratemporal fossa.

inability to 'pop' or 'clear' the ear with changes in barometric pressure

For example, when travelling in a lift or an aeroplane.

normal head and neck examination

Patients may have an entirely normal head and neck examination.

Other diagnostic factors

common

aural fullness

May be exacerbated by a peak of allergic rhinitis or chronic rhinosinusitis.

subjective hearing loss

Patients may complain of a sense of hearing loss.

This is subjective rather than actual and occurs due to an inability to 'pop' or 'clear' the ears with changes in barometric pressure, such as when ascending or descending in a lift or an aeroplane.

autophony

Associated with patulous Eustachian tubes. The patient will report resolution with supine position or leaning the head forwards.

history of serous otitis media or of chronic otitis media

A repeated history of otitis media may be given.

oedema of the Eustachian tube orifice

Noted on nasal endoscopy.

history of retracted or hypermobile tympanic membrane

This may be particularly in the weak pars flaccida area.

Risk factors

strong

cleft palate

The incidence of ETD may be as high as 79% in patients with cleft palate. The possible mechanisms for this include a more horizontal course of the Eustachian tube, abnormal attachments of the muscles involved with Eustachian tube opening, or inadequate function of these muscles.[13][14]

adenoid hypertrophy

Hypertrophied adenoids directly obstruct the Eustachian tube orifice. They may also impair drainage of secretions from the tube, through metaplasia of the mucosa to non-ciliated epithelium and fibrosis of connective tissue in the adenoid tissue.[15] This is more common in children than in adults with ETD.

allergic rhinitis

It has been reported that there is a >50% rate of allergic rhinitis in patients with otitis media, and that allergic children suffer from otitis media twice as often as non-allergic patients.[16][17][18] The implication with regard to ETD is that allergic inflammatory changes in the nose or directly in the Eustachian tube itself cause dysfunction of the tube, with resultant otitis media.

chronic rhinosinusitis

An association of chronic rhinosinusitis with ETD has been demonstrated in observational studies. Patient-reported symptoms consistent with clinically significant ETD have been reported in 43% to 47% of patients evaluated in a tertiary rhinology clinic.[19][20] Endoscopic sinus surgery for the treatment of chronic rhinosinusitis has been associated with normalisation of ETD symptoms.[21]

neoplasm of nasopharynx or infratemporal fossa

These neoplasms may cause direct obstruction of the Eustachian tube, leading to impaired function. Most commonly, this presents as a unilateral serous otitis media.

Eustachian tube trauma

Extrinsic compression of the tube from trauma, though rare, may be a cause.[13][22]

Eustachian tube infection

Viral upper respiratory infections are associated with ETD.[23][24]

weak

age <5 years

ETD is most common in children under the age of 5 years, and diminishes in frequency into adulthood.

cigarette smoking

Causes impedance of mucociliary clearance.[25]

GORD

Causes impedance of mucociliary clearance.[26]

radiation exposure

Causes impedance of mucociliary clearance.[27]

history of recent weight loss

Recent significant weight loss is associated with patulous Eustachian tubes. This is believed to be due to loss of volume of the fat pad which surrounds the cartilaginous portion of the Eustachian tube.

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